Prudential Flip Flops on LTD Benefits for Over Two Years

AETNA Reverses Termination Decision on Appeal
February 27, 2018
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Prudential Flip Flops on LTD Benefits for Over Two Years

Thinking about my last post, I thought it appropriate to note that sometimes an insurer’s reinstatement of LTD benfits is short-lived. In a matter in which we are presently engaged, Prudential has denied benefits, reinstated, denied again, and reinstated again since May 2008. So even when an insurer relents in the face of a meritorious appeal, it rarely gives up.

The facts of my client’s claim with Prudential are not uncommon. She stopped working in March 2006 and the medical records and her treating physicians’ opinions confirmed her inability to perform the duties of her regular occupation for a bank. Prudential approved her claim and paid benefits from May 2006 through May 2008. On review under the any occupation definition of disability, Prudential decided based on a file review by its nurse consultant that our client could be gainfully employed in other occupations. It refused to pay benefits beyond May 31, 2008.

The client hired Shook & Johnson and we prosecuted a first level appeal. We won. On March 30, 2009, Prudential determined to reinstate LTD benefits.

But Prudential warned that it would continue to obtain and evaluate medical records to assure that our client continued to meet all the contractual requirements for benefits. On August 25, 2009, Prudential thought it found another way and it terminated benefits again.

As required under the Plan, and as a pre-condition to filing a lawsuit against Prudential, we submitted a first level appeal. Of course, there is pre-appeal submission work to be done to address and overcome the denial rationale of an insurer. And so there was in our matter with Prudential. We submitted the appeal and all appropriate additional medical records in January 2010.

Prudential denied the first level appeal in April 2010. In reasoning that was mind-boggling, Prudential decided our client had no significant impairment, restriction, or limitation that would prevent her from doing “whatever she wanted to do.”

We pursued a voluntary second level appeal to expose the flaws of an IME relied upon by Prudential (and doing so would improve our record for judicial review if we latered sued). We submitted our second level appeal, along with appropriate additional records, in September 2010. Again, Prudential yielded. In November 2010, Prudential determined our client was eligible for benefits and reinstated the same back to September 2009.

I wish I could say that our 62 year-old client will be free from further hassle by Prudential. With all her medical problems, she’s entitled to a little peace. But I can’t say what I don’t believe. More often than not, winning on appeal with an insurer in an LTD claim means you’ve won a skirmish but the war continues.

If your battling an insurer over an LTD claim, call us for a free, no obligation consultation at (877) 293-1122.